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Important information about your health benefits For Aetna
LeapSM plans, including these networks: Mercy Medical Center MIPPA
Patient Preferred UnityPoint Health Cedar Rapids UnityPoint Health
Des Moines UnityPoint Health Quad Cities UnityPoint Health
Waterloo
Aetna is the brand name used for products and services provided
by one or more of the Aetna group of subsidiary companies. Health
benefits plans are provided by Aetna Health Inc.
https://myaetna.com
01.28.336.1 (9/16)
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Understanding your plan of benefits Aetna health benefits plans
cover most types of health care from a doctor or hospital, but they
do not cover everything. The plan covers recommended preventive
care and care you need for medical reasons. It does not cover
services you may just want to have, like plastic surgery. It also
does not cover treatment that is not yet widely accepted. You
should also be aware that some services may have limits. For
example, a plan may allow only one eye exam per year.
Where to find information about your specific plan Your plan
documents list all the details for the plan you chose. This
includes whats covered, whats not covered and what you will pay for
services. Plan document names vary. They may include a Policy and
Schedule of Benefits and updates that come with them.
If you cant find your plan documents, call the toll-free number
on your digital member ID card to ask for a copy.
Get plan information online and by phone
Existing members If youre already an Aetna member, you have two
convenient ways to get plan information anytime, day or night:
1. L og in to your secure member website at https://myaetna.com.
You can get coverage information for your plan online. You can also
get details about any programs, tools and other services that come
with your plan. Just register once to create a user name and
password.
Visit https://myaetna.com and click Sign Up. Follow the prompts
to complete the one-time registration. Then you can log in anytime
to:
Access your digital member ID card
Verify whos covered and whats covered
Access your plan documents
Track claims or view past copies of Explanation of Benefits
statements
Use the provider search tool to find in-network care
Learn more about and access any wellness programs that come with
your plan
2. Call the toll-free number on your digital member ID card.
You can speak with an advocate to:
Understand how your plan works and your share of costs
Get information about how to file a claim
Find care outside your area
File a complaint or appeal
Get copies of your plan documents
Connect to behavioral health services
Find specific health information
Learn more about our quality management program
Not yet a member? You can call us at 1-844-269-3751 if you need
help understanding how a particular medical plan works.
Search your plans network for doctors, hospitals and other
health care providers Use the online provider search tool for the
most up-to-date list of health care professionals and facilities.
You can get a list of available doctors by ZIP code, or enter a
specific doctors name in the search field. You can access the
search tool as follows:
Existing members: Log in to your secure member website at
https://myaetna.com.
Considering enrollment: Visit the applicable website below.
Illinois: https://buyhealthinsurance. aetna.com/?state=IL
Iowa: https://buyhealthinsurance. aetna.com/?state=IA
Nebraska: https:// buyhealthinsurance.aetna. com/?state=NE
Our online search tool is more than just a list of doctors names
and addresses. It also includes information about:
Where the physician attended medical school
Board certification status
Language spoken
Hospital affiliations
Gender
Driving directions
Get a FREE printed directory To get a free printed list of
doctors and hospitals, call the toll-free number on your digital
member ID card. If youre not yet a member, call 1-844-269-3751.
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Help for those who speak another language and for the hearing
impaired If you require language assistance, please call the number
on your digital member ID card, and an Aetna representative will
connect you with an interpreter. You can also get interpretation
assistance for utilization management issues or for registering a
complaint or appeal. If youre deaf or hard of hearing, use your TTY
and dial 711 for the Telecommunications Relay Service. Once
connected, please enter or provide the Aetna telephone number youre
calling.
Ayuda para las personas que hablan otro idioma y para personas
con impedimentos auditivos Si usted necesita asistencia lingstica,
por favor llame al nmero que aparece en su tarjeta de identificacin
digital para el miembro, y un representante de Aetna le conectar
con un intrprete. Tambin puede recibir asistencia de interpretacin
para asuntos de administracin de la utilizacin o para registrar una
queja o apelacin. Si usted es sordo o tiene problemas de audicin,
use su TTY y marcar 711 para el Servicio de Retransmisin de
Telecomunicaciones (TRS). Una vez conectado, por favor entrar o
proporcionar el nmero de telfono de Aetna que est llamando.
What you pay You will share in the cost of your health care.
These are called out-of-pocket costs. Your plan documents show the
amounts that apply to your specific plan. Those costs may
include:
Copay A set amount (for example, $25) you pay for covered health
care
service. You usually pay this when you get the service. The
amount can vary by the type of service. For example, you may pay a
different amount to see a specialist than you would pay to see your
family doctor.
Deductible The amount you owe for health care services before
your health plan begins to pay. For example, if your deductible is
$2,500, you have to pay the first $2,500 for covered services
before the plan begins to pay. You may not have to pay for some
services.
Your costs when you go outside the network We cover the cost of
care based on if the health care provider, such as a doctor or
hospital, is in network or out of network.
In network means we have a contract with that provider.
Providers agree to how much they will charge you for covered
services. That amount is often less than what they would charge if
they were not in our network. Most of the time, it costs you less
to use doctors and hospitals in our network. They also agree to not
bill you for any amount over their contract rate. All you have to
pay is your copayments along with any deductible. Your network
provider will handle any precertification required by your
plan.
Out of network means we do not have a contract for discounted
rates with that health care provider. We dont know exactly what an
out-of-network provider will charge you. If you choose a provider
who is out of network, your Aetna health plan may pay some of that
doctors bill. Most of the time, you will pay more money out of your
own pocket if you choose to use an out-of-network provider.
Your out-of-network doctor or hospital sets the rate to charge
you. It may be higher sometimes much higher than what your Aetna
plan recognizes or allows. Your doctor may bill you for the dollar
amount that the plan
doesnt recognize. Youll also pay higher copayments, coinsurance
and deductibles under your plan. No dollar amount above the
recognized charge counts toward your deductible or out-of-pocket
limits. This means that you are fully responsible for paying
everything above the amount that the plan allows for a service or
procedure.
When you choose to see an out-of-network provider, we pay for
your health care depending on the plan you or your employer
chooses. Some of our plans pay for out-of-network services by
looking at what Medicare would pay and adjusting that amount up or
down. Our plans range from paying 90 percent of Medicare (that is,
10 percent less than Medicare would pay) to 300 percent of Medicare
(the Medicare rate multiplied by three). Some plans pay for
out-of-network services based on what is called the usual and
customary charge or reasonable amount rate. These plans use
information from FAIR Health, Inc., a not-for-profit company, that
reports how much providers charge for services in any ZIP code.
You can call the toll-free number on your Aetna ID card to find
out the method your plan uses to reimburse out-of-network
providers. You can also ask for an estimate of your share of the
cost for out-of-network services you are planning. The method of
paying out-of-network doctors and hospitals applies when you choose
to get care out of network. See Emergency and urgent care and care
after office hours to learn more.
Going in network just makes sense
We have negotiated discounted rates for you.
In-network doctors and hospitals wont bill you for costs above
our rates for covered services.
You are in great hands with access to quality care from our
network.
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Our network health care providers are in two groups: Tier 1 and
Tier 2 Both provide high-quality care. But Tier 1 providers cost
you less, every time you get care. Once you meet the Tier 1
deductible, youre covered in full. Just as long as you continue to
see Tier 1 providers. But, if you choose to see Tier 2 providers
after youve met your Tier 1 deductible, your deductible gets bumped
up. A lot. You can find the Tier deductibles listed in the plan
documents.
When using the provider search tool, dont forget to check out
the providers network status and whether theyre Tier 1 or Tier 2
for each plan. Remember, tiering affects what youll pay out of
pocket like how much you spend on care and whether or not you get
that great Tier 1 discount. See Search your plans network for
doctors, hospitals and other health care providers in this booklet
for more.
Precertification: getting approvals for services Sometimes we
will pay for care only if we have given an approval before you get
it. We call that precertification. You usually only need
precertification for more serious care like surgery or being
admitted to a hospital. Your plan documents list all the services
that require this approval. When you receive care from a doctor in
the network, your doctor gets precertification from us.
You do not have to get precertification for emergency
services.
What we look for when reviewing a request First, we check to see
that you are still a member. And we make sure the service is
considered medically necessary for your condition. We also make
sure the service and place requested to perform the service are
cost-effective. Our decisions are based entirely on appropriateness
of care and service and the existence of coverage, using nationally
recognized guidelines and resources. We may suggest a different
treatment or place of service that is just as effective but costs
less. We also look to see if you qualify for one of our care
management programs. If so, one of our nurses may contact you.
Precertification does not verify if you have reached any plan
dollar limits or visit maximums for the service requested. So, even
if you get approval, the service may not be covered.
Our review process after precertification (utilization review/
patient management) We have developed a patient management program
to help you access appropriate health care and maximize coverage
for those health care services. In certain situations, we review
your case to be sure the service or supply meets established
guidelines and is a covered benefit under your plan. We call this a
utilization review.
We follow specific rules to help us make your health a top
concern during our reviews We do not reward Aetna employees
for denying coverage.
We do not encourage denials of coverage. In fact, we train staff
to focus on the risks of members not getting proper care. Where
such use is appropriate, our staff uses nationally recognized
guidelines and resources, such as MCG (formerly Milliman Care
Guidelines) to review requests for coverage. Physician groups, such
as independent practice
associations, may use other resources they deem appropriate.
We do not encourage utilization decisions that result in
underutilization.
If you have a chronic condition or an upcoming hospital stay You
may qualify for one of our care management programs.
An Aetna nurse can be the extra support you need.
After you enroll, just call the number on your ID card to learn
more.
You never need referrals with Aetna Open Access plans As an
Aetna Open Access or preferred provider organization (PPO) plan
member, you never need a referral from your regular doctor to see a
specialist. You also do not need to select a primary care physician
(PCP), but we encourage you to do so to help you navigate the
health care system.
Women have direct access to their Ob/Gyn Any female member 13
years or older may visit any participating gynecologist for a
routine well-woman exam, including a Pap smear when appropriate and
an unlimited number of visits for gynecologic problems and
follow-up care.
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Information about specific benefits
Emergency and urgent care and care after office hours An
emergency medical condition means your symptoms are sudden and
severe. If you dont get help right away, an average person with
average medical knowledge will expect that you could die or risk
your health. For a pregnant woman, that includes her unborn
child.
Emergency care is covered anytime, anywhere in the world. If you
need emergency care, follow these guidelines:
Call 911 or go to the nearest emergency room. If you have time,
call your doctor.
Tell your doctor as soon as possible afterward. A friend or
family member may call on your behalf.
You do not have to get approval for emergency services.
Emergency care is covered Sometimes, you dont have a choice
about where you go for care, like in an emergency. When you need
emergency care, well treat it like you got the care in network,
even if you received it from an out-of-network provider. Emergency
care is subject to your deductible. This means if youve already met
your deductible, theres no charge to you.
Also, we may pay less than what an out-of-network provider
charges. Dont worry, for an emergency situation, you dont have to
pay it. If the provider bills you for the rest of the cost, just
call us at the toll-free number on your digital member ID card and
well take care of it.
See your plan documents and the No coverage based on U.S.
sanctions section in this booklet for more information.
After-hours care available 24/7 Call your doctor when you have
medical questions or concerns. Your doctor should have an answering
service if you call after the office closes. You can also go to an
urgent care center, which may have limited hours. To find a center
near you, log in at https://myaetna.com and search our list of
doctors and other health care providers. Check your plan documents
to see how much you must pay for urgent care services.
Prescription drug benefit When your doctor prescribes you a
drug, then its time to use your pharmacy coverage. Use it well, and
it can save you money. Heres how:
You have coverage when you use a network There is no coverage
when you use an out-of-network pharmacy. The pharmacy network may
change from time to time. Your secure member website will have the
most up-to-date information.
Find a network pharmacy near you online Before you fill a
prescription, go to your secure member website. There you can find
network pharmacies near you. Browse our directory, or you can look
them up just like you would a doctor or hospital. See Search your
plans network for doctors, hospitals and other health care
providers in this booklet for more.
You can look up your drugs and know the costs ahead of time on
your secure member website Youll find your cost for each drug by
pharmacy. You can also compare the cost at a local pharmacy with
your cost for mail order to see how much you can save.
Some plans encourage generic drugs over brand-name drugs Many
brand-name drugs have generic versions with the same active
ingredients. Or there may be a different generic drug that can
treat your condition. Generic drugs are as safe and effective as
their brand-name versions. For certain drugs, you must get the
generic. That doesnt mean you cant use a brand-name drug, but youll
pay more for it. Youll pay your normal share of the cost, and youll
also pay the difference in the two prices.
We may also encourage you to use certain drugs Some plans
encourage you to buy certain prescription drugs over others. The
plan may even pay a larger share for those drugs. We list those
drugs in the preferred drug guide (also known as a formulary). This
guide shows which prescription drugs are covered under your plan.
It also explains how we choose drugs to be in the guide. When you
get a drug that is not covered under your plan, your share of the
cost may be more.
Get convenient refills through home delivery Home delivery and
specialty drug services are from pharmacies that Aetna owns. Aetna
Rx Home Delivery and Aetna Specialty Pharmacy are included in your
network and provide convenient options for filling medicine you
take every day or specialty medicines that treat complex
conditions.
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You may have to get approval before some drugs are covered
Sometimes your doctor might recommend a drug thats not covered
under your plan. If it is medically necessary for you to use that
drug, you, someone helping you or your doctor can ask us to make an
exception. Your pharmacist can also ask for an exception for
antibiotics and pain medicines. Check your plan documents for
details.
You may have to try one drug before you can try another Step
therapy means you may have to try one or more less expensive or
more common drugs before a drug on the step-therapy list will be
covered. Your doctor might want you to skip one of these drugs for
medical reasons. If so, you, someone helping you or your doctor can
ask for an exception through the precertification process.
You may request an exception for some drugs that are not covered
Your plan documents might list specific drugs that are not covered.
Your plan may also not cover drugs that we havent reviewed yet.
You, someone helping you or your doctor may have to get our
approval (a medical exception) to use one of these drugs.
Find out what drugs your plan covers You can find covered drugs
on your secure member website. Or you can call the toll-free number
on your digital member ID card to ask for a printed copy of the
covered drug list. We may sometimes change the drugs we cover. Look
online or call the toll-free number on your digital member ID card
for the latest updates.
Mental health and addiction benefits You must use therapists and
other mental health professionals who are in the Aetna network.
Heres how to get inpatient and outpatient services, partial
hospitalization and other mental health services:
Call 911 if its an emergency.
Use the online provider search tool at https://myaetna.com.
Call the toll-free number on your digital member ID card.
Transplants and other complex conditions Our National Medical
Excellence Program is for members who need a transplant or have a
condition that can only be treated at a certain hospital. You may
need to visit an Institutes of ExcellenceTM hospital to get
coverage for the treatment. Some plans wont cover the service if
you dont.
We choose hospitals for the National Medical Excellence Program
based on their expertise and experience with these services. We
also follow any state rules when choosing these hospitals.
Important benefits for women
Womens Health and Cancer Rights Act of 1998 Your Aetna health
plan provides benefits for mastectomy and mastectomy-related
services, including all stages of reconstruction and surgery to
achieve symmetry between breasts; prosthesis; and treatment of
physical complications of all stages of mastectomy, including
lymphedema. Coverage is provided in accordance with your plan
design and is subject to plan limitations, copays, deductibles and
referral requirements,
if any, as outlined in your plan documents. Please call the
toll-free number on your member ID card for more information.
For more information, you can visit the U.S. Department of
Health and Human Services website, www.cms.gov/
CCIIO/Programs-and-Initiatives/ Other-Insurance-Protections/
whcra_factsheet.html, and the U.S. Department of Labor website,
www.dol.gov/ebsa/consumer_info_ health.html.
No coverage based on U.S. sanctions If U.S. trade sanctions
consider you a blocked person, the plan cannot provide benefits or
coverage to you. If you travel to a country sanctioned by the
United States, the plan in most cases cannot provide benefits or
coverage to you. Also, if your health care provider is a blocked
person or is in a sanctioned country, we cannot pay for services
from that provider. For example, if you receive care while
traveling in another country and the health care provider is a
blocked person or is in a sanctioned country, the plan cannot pay
for those services. For more information on U.S. trade sanctions,
visit www.treasury.gov/ resource-center/sanctions/Pages/
default.aspx.
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How we determine whats covered Avoid unexpected bills. Check
your plan documents to see whats covered before you get health
care. Cant find your plan documents? Call the toll-free number on
your digital member ID card to ask a specific question or have a
copy mailed to you.
Here are some of the ways we determine what is covered:
We check if its medically necessary Medical necessity is more
than being ordered by a doctor. Medically necessary means your
doctor ordered a product or service for an important medical
reason. It might be to help prevent a disease or condition, or to
check if you have one. Or it might be to treat an injury or
illness.
The product or service:
Must meet a normal standard for doctors
Must be the right type in the right amount for the right length
of time and for the right body part
Must be known to help the particular symptom
Cannot be for the members or the doctors convenience
Cannot cost more than another service or product that is just as
effective
Only medical professionals can decide if a treatment or service
is not medically necessary. We do not reward Aetna employees for
denying coverage. Sometimes a physicians group will determine
medical necessity. Those groups might use different resources than
we do.
If we deny coverage, well send you and your doctor a letter. The
letter will explain how to appeal the denial. You
have the same right to appeal if a physicians group denied
coverage. You can call the toll-free number on your member ID card
to ask for a free copy of the materials we use to make coverage
decisions. Doctors can write or call our Patient Management
department with questions. Contact us either online or at the phone
number on your member ID card for the appropriate address and phone
number.
Iowa Coverage decision means a final adverse decision based on
medical necessity. This definition does not include a denial of
coverage for a service or treatment specifically listed in the plan
documents as excluded from coverage, or a denial of coverage for a
service or treatment that has already been received and for which
the enrollee has no financial liability.
We study the latest medical technology We look at scientific
evidence published in medical journals to help us decide what is
medically necessary. This is the same information doctors use. We
also make sure the product or service is in line with how doctors,
who usually treat the illness or injury, use it. Our doctors may
use nationally recognized resources like MCG (formerly Milliman
Care Guidelines).
We also review the latest medical technology, including drugs,
equipment and mental health treatments. Plus, we look at new ways
to use old technologies. To make decisions, we may:
Read medical journals to see the research. We want to know how
safe and effective it is.
See what other medical and government groups say about it. That
includes the federal Agency for Healthcare Research and
Quality.
Ask experts.
Check how often and how successfully it has been used.
We post our findings on www.aetna.com After we decide if a
product or service is medically necessary, we write a report about
it. We call the report a Clinical Policy Bulletin (CPB).
CPBs help us decide whether to approve a coverage request. Your
plan may not cover everything our CPBs say is medically necessary.
Each plan is different, so check your plan documents.
CPBs are not meant to advise you or your doctor on your care.
Only your doctor can give you advice and treatment. Talk to your
doctor about any CPB related to your coverage or condition.
You and your doctor can read our CPBs on our website at
www.aetna.com. Enter Clinical Policy Bulletin in the search bar. No
Internet? Call us at the toll-free number on your digital member ID
card. You can ask for a copy of any CPB named in a denial
letter.
What to do if you disagree with us
Complaints, appeals and external review Please tell us if you
are not satisfied with a response you received from us or with how
we do business.
You can designate a representative to participate in the
complaint or grievance process. All disputes involving denial of
payment for a health care service will be made by qualified
personnel with experience in the same or similar scope of
practice.
Call the toll-free number on your member ID card to file a
verbal
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complaint or to ask for the address to mail a written complaint.
You can also send an email through your secure member website. See
Get plan information online and by phone for more information.
If youre not satisfied after talking to a health plan
representative, you can ask us to send your issue to the
appropriate complaint department.
If you dont agree with a decision related to a denied claim, you
can file an appeal. To file an appeal, follow the directions in the
letter or Explanation of Benefits statement that explains that your
claim was denied. The letter will also include information about
the basis for the denial, what we need from you if you wish to
appeal the decision and how soon we will respond to your
appeal.
A rush review may be possible
If your doctor thinks you cannot wait 45 days, ask for an
expedited review. That means we will make our decision as soon as
possible.
Get a review from someone outside Aetna If the denial is based
on a medical judgment, you may be able to get an outside review if
youre not satisfied with your appeal (in most cases you will need
to finish all of your internal appeals first). Follow the
instructions on our response to your appeal. Call the toll-free
number on your member ID card to ask for an external review form.
You can also visit https://myaetna.com. Enter external review into
the search bar.
An independent review organization (IRO) will assign your case
to one of their experts. The expert will be a doctor or other
professional who specializes in that area or type of appeal. You
should have a decision within 45 calendar days of the request. The
outside reviewers decision is final and binding; we will follow the
outside reviewers decision and you will not
have to pay anything unless there was a filing fee.
Some states have their own external review process, and you may
need to pay a small filing fee as part of the state-mandated
program. In other states, external review is still available but
follows federal rules. Visit your states government website to
learn more. You can find a link at
www.usa.gov/Agencies/State-and-Territories.shtml or call Member
Services at the toll-free number on your Aetna ID card for
help.
Member rights and responsibilities
Know your rights as a member You have many legal rights as a
member of a health plan. You also have many responsibilities. You
have the right to suggest changes in our policies and procedures.
This includes our member rights and responsibilities.
Some of your rights are below. We also publish a list of rights
and responsibilities on our website. Visit www.aetna.com and enter
rights and resources into the search bar to view the list. You can
also call the number on your digital member ID card to request a
printed copy or for more information.
Making medical decisions before your procedure An advance
directive tells your family and doctors what to do when you cant
tell them yourself. You dont need an advance directive to receive
care, but you have the right to create one. Hospitals may ask if
you have an advance directive when you are admitted.
There are three types of advance directives:
Durable power of attorney names the person you want to make
medical decisions for you.
Living will spells out the type and extent of care you want to
receive.
Do-not-resuscitate order states that you dont want CPR if your
heart stops or a breathing tube if you stop breathing.
You can create an advance directive in several ways:
Ask your doctor for an advance directive form.
Write your wishes down by yourself.
Pick up a form at state or local offices on aging, or your local
health department.
Work with a lawyer to write an advance directive.
Create an advance directive using computer software designed for
this purpose.
Source: American Academy of Family Physicians. Advance
directives and do not resuscitate orders. January 2012. Available
at http:// familydoctor.org/familydoctor/en/ healthcare-management/
end-of-life-issues/advance-directives-and-do-not-resuscitate-orders.html.
Accessed June 10, 2016.
Learn more about care management and quality management programs
We make sure your doctor provides quality care for you and your
family. To learn more about these programs, log in to your secure
member website at https://myaetna.com. Enter commitment to quality
in the search bar. You can also call the toll-free number on your
digital member ID card to ask for a printed copy.
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We protect your privacy We consider personal information to be
private. Our policies protect your personal information from
unlawful use. By personal information, we mean information that can
identify you as a person, as well as your financial and health
information.
Personal information does not include what is available to the
public. For example, anyone can access information about what the
plan covers. It also does not include reports that do not identify
you.
Summary of the Aetna privacy policy When necessary for your care
or treatment, the operation of our health plans or other related
activities, we use personal information within our company, share
it with our affiliates and may disclose it to:
Your doctors, dentists, pharmacies, hospitals and other
caregivers
Other insurers
Vendors
Government departments
Third-party administrators (TPAs)
These parties are required to keep your information private as
required by law.
Some of the ways in which we may use your information
include:
Paying claims
Making decisions about what the plan covers
Coordination of payments with other insurers
Quality assessment
Activities to improve our plans
Audits
We consider these activities key for the operation of our plans.
When allowed by law, we use and disclose your personal information
in the ways explained above without your permission. Our privacy
notice
includes a complete explanation of the ways we use and disclose
your information. It also explains when we need your permission to
use or disclose your information.
We are required to give you access to your information. If you
think there is something wrong or missing in your personal
information, you can ask that it be changed. We must complete your
request within a reasonable amount of time. If we dont agree with
the change, you can file an appeal.
For more information about our privacy notice or if youd like a
copy, call the toll-free number on your digital member ID card or
visit us at https://myaetna.com.
Anyone can get health care We do not consider your race,
disability, religion, sex, gender identity, sexual orientation,
health, ethnicity, creed, age or national origin when giving you
access to care. Network providers are legally required to the
same.
We must comply with these laws:
Title VI of the Civil Rights Act of 1964
Age Discrimination Act of 1975
Americans with Disabilities Act
Laws that apply to those who receive federal funds
All other laws that protect your rights to receive health
care
How we use information about your race, ethnicity and the
language you speak You choose if you want to tell us your
race/ethnicity and preferred language. Well keep that information
private. We use it to help us improve your access to health care.
We also use it to help serve you better. See We protect your
privacy to learn more about how we use and protect your private
information. See also Anyone can get health care.
Your rights to enroll later if you decide not to enroll now
When you lose your other coverage You might choose not to enroll
now because you already have health insurance. You may be able to
enroll later if you lose that other coverage. This includes
enrolling your spouse or children and other dependents. If that
happens, you must apply within 60 days before you expect to lose
coverage and 60 days after your coverage has ended.
When you have a new dependent Getting married? Having a baby? A
new dependent changes everything. And you can change your mind. You
can enroll within 60 days after certain life events if you chose
not to enroll during the normal open enrollment period. These life
events include:
Marriage
Birth
Adoption
Placement for adoption
For more information or to request special enrollment, you can
call the toll-free number on your digital member ID card. If you
are not a member yet, you can call 1-844-269-3751.
9
https://myaetna.com
-
More information is available
Illinois Illinois law requires health plans to provide the
following information each year to enrollees and to prospective
enrollees upon request:
A complete list of participating health care providers in the
health care plans service area
A description of the following terms of coverage:
1. The service area
2. The covered benefits and services with all exclusions,
exceptions and limitations
3. The precertification and other utilization review procedures
and requirements
4. A description of the process for the selection of a PCP, any
limitation on access to specialists and the plans standing referral
policy
5. The emergency coverage and benefits, including any
restrictions on emergency care services
6. The out-of-area coverage and benefits, if any
7. The enrollees financial responsibility for copayments,
deductibles, premiums and any other out-of-pocket expenses
8. The provisions for continuity of treatment in the event a
health care providers participation terminates during the course of
an enrollees treatment by the provider
9. The appeals process, forms and time frames for health care
services appeals, complaints and external independent reviews,
administrative complaints and utilization review complaints,
including a phone number to call to receive more information from
the health care plan concerning the appeals process
10. A statement of all basic health care services and all
specific benefits and services to be provided to enrollees by a
state law or administrative rule
A description of the financial relationship between the health
plan and any health care provider, including, if requested, the
percentage of copayments, deductibles and total premiums spent on
health care related expenses and the percentage of copayments,
deductibles and total premiums spent on other expenses, including
administrative expenses
10
-
-
Aetna does not discriminate on the basis of race, color,
national origin, disability, age, sex, gender identity, sexual
orientation or health status in the administration of the plan,
including enrollment and benefit determinations.
We are committed to Health Plan Accreditation by the National
Committee for Quality Assurance (NCQA) as a means of demonstrating
a commitment to continuous quality improvement and meeting customer
expectations. You can find a complete list of health plans and
their NCQA status on the NCQA website located at www.ncqa.org.
Click on the Report Cards tab to search on Health Plans.
To refine your search for other health care providers, click on
Clinicians or Other Healthcare Organizations. The link for
Clinicians includes doctors recognized by NCQA in the areas of
heart/stroke care, diabetes care, patient centered medical home and
patient centered specialty practice. The recognition programs are
built on evidence-based, nationally recognized clinical standards
of care; therefore, NCQA provider recognition is subject to change.
You can access the official NCQA directory of recognized clinicians
at http://recognition.ncqa.org. The link for Other Healthcare
Organizations includes Managed Behavioral Healthcare Organizations
for behavioral health accreditation and Credentials Verifications
Organizations for credentialing certification.
If you need this material translated into another language,
please call 1--844-269--3751. Si usted necesita este material en
otro lenguaje, por favor llame al 1--844-269--3751.
https://myaetna.com
2016 Aetna Inc. 01.28.336.1 (9/16)
http://recognition.ncqa.orghttp://www.ncqa.org
-
Nondiscrimination Notice
Aetna complies with applicable federal civil rights laws and
does not discriminate on the basis of race, color, national origin,
age, disability or sex. Aetna does not exclude people or treat them
differently because of race, color, national origin, age,
disability, or sex.
Aetna:
Provides free aids and services to people with disabilities to
communicate effectively with us, such as:
o Qualified sign language interpreters o Written information in
other formats (large print, audio, accessible electronic
formats,
other formats) Provides free language services to people whose
primary language is not English, such as:
o Qualified interpreters o Information written in other
languages
If you need these services, contact our Civil Rights
Coordinator.
If you believe that Aetna has failed to provide these services
or discriminated in another way on the basis of race, color,
national origin, age, disability or sex, you can file a grievance
with our Civil Rights Coordinator at:
Address: P.O. Box 14462, Lexington, KY 40512 (CA HMO customers:
PO Box 24030 Fresno, CA 93779) Telephone: 1-800-648-7817 (TTY:
711), Fax: 1-859-425-3379 (CA HMO customers: 860-262-7705) Email:
[email protected]
You can file a grievance in person or by mail, fax or email. If
you need help filing a grievance, our Civil Rights Coordinator is
available to help you.
You can also file a civil rights complaint with the U.S.
Department of Health and Human Services, Office for Civil Rights
electronically through the Office for Civil Rights Complaint
Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone
at: U.S. Department of Health and Human Services, 200 Independence
Avenue, SW Room 509F, HHH Building, Washington, D.C. 20201,
1-800-368-1019, 800-537-7697 (TDD).
Complaint forms are available at
http://www.hhs.gov/ocr/office/file/index.html.
Aetna is the brand name used for products and services provided
by one or more of the Aetna group of subsidiary companies,
including Aetna Life Insurance Company, and its affiliates.
http://www.hhs.gov/ocr/office/file/index.htmlhttps://ocrportal.hhs.gov/ocr/portal/lobby.jsfmailto:[email protected]
-
TTY: 711
For language assistance in English call 855.425.8706 at no cost.
(English)
Para obtener asistencia lingstica en espaol, llame sin cargo al
855.425.8706. (Spanish)
855.425.8706 (Chinese)
Pour une assistance linguistique en franais appeler le
855.425.8706 sans frais. (French)
Para sa tulong sa wika na nasa Tagalog, tawagan ang 855.425.8706
nang walang bayad. (Tagalog)
855.425.8706 (Navajo)
Bentigen Sie Hilfe oder Informationen in deutscher Sprache?
Rufen Sie uns kostenlos unter der Nummer 855.425.8706 an.
(German)
855.425.8706 (Amharic)
)!cijak* .855.425.8706 ) *
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Gargaarsa afaan Oromiffa hiikuu argachuuf lakkokkofsa bilbilaa
855.425.8706 irratti bilisaan bilbilaa. (Cushite)
Bel voor tolk- en vertaaldiensten in het Nederlands gratis naar
855.425.8706. (Dutch)
Pou jwenn asistans nan lang Kreyl Ayisyen, rele nimewo
855.425.8706 gratis. (French Creole)
855.425.8706 . (Greek)
)Gujarati* 855.425.8706 .
)Hindi* , 855.425.8706
Yog xav tau kev pab txhais lus Hmoob hu dawb tau rau
855.425.8706. (Hmong)
Maka enyemaka ass na Igbo kp 855.425.8706 na akwgh gw bla
(Ibo)
Per ricevere assistenza linguistica in italiano, pu chiamare
gratuitamente 855.425.8706. (Italian)
855.425.8706 (Japanese)
v>w>frRp>Rw>fuwdRusd.ft*D>f usd.f ud;
855.425.8706 v>wtd.f'D;w>fv>mfbl.fv>mfphRb.f
(Karen)
-
855.425.8706 .
(Korean)
m ke gbo-kpa-kpa dye pidyi e as-wuuun w, a 855.425.8706
(Kru-Bassa)
)hurdiuK* . 855.425.8706
, 855.425.8706 . (Laotian) 855.425.8706 (MonKhmer, Cambodian)
(m) 855.425.8706 (Nepali)
Fer Helfe in Deitsch, ruf: 855.425.8706 aa. Es Aaruf koschtet
nix. (Pennsylvanian Dutch)
)Persian* . 855.425.8706
!by uzyska pomoc w jzyku polskim, zadzwo bezpatnie pod numer
855.425.8706. (Polish)
Para obter assistncia lingustica em portugus ligue para o
855.425.8706 gratuitamente. (Portuguese) , 855.425.8706. (
Russian)
Za jezinu pomo na hrvatskom jeziku pozovite besplatan broj
855.425.8706. (Serbo-Croatian)
)cryssSnzzryssA* 8554258706
855.425.8706 . )* )Telugu* 855.425.8706 (Thai)
, 855.425.8706. (Ukrainian)
) urdu* 855.425.8706 c h tr ngn ng bng (ngn ng), hay goi min phi
n s 855.425.8706. (Vietnamese) Fn rnlw npa d (Yorb) pe 855.425.8706
li san ow kankan rr. (Yoruba)
n n
CB-General-HNOption-Disclosure-2016CoverUnderstanding your plan
of benefitsGet plan information online and by phoneSearch your
plans network for doctors, hospitals and other health care
providersHelp for those who speak another language and for the
hearing impairedWhat you payOur network health care providers are
in two groups: Tier 1 and Tier 2Precertification: getting approvals
for servicesYou never need referrals with Aetna Open Access
plansInformation about specific benefitsHow we determine whats
coveredWhat to do if you disagree with usMember rights and
responsibilitiesBack CoverNondiscrimination NoticeTTY: 711
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